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Cavitating Lung Lesion and Recurrent Chest Infections

Case Editor - Judd Flesch

Reviewed By Microbiology, Tuberculosis & Pulmonary Infections Assembly

Submitted by

Deirdre O’Riordan, M.D.

Consulting Physician

Respiratory Medicine

St. James Hospital

Dublin, Ireland

Fiona Kevitt, M.B., B.Ch., B.A.O.

Senior Medical House Officer

Internal Medicine

St. James Hospital

Dublin, Ireland

Submit your comments to the author(s).


A 70-year-old man presented with 6-month history of recurrent "chest infections." He had a cough which was productive initially, then became dry. He complained of dyspnoa on exertion, general fatigue, decreased appetite and weight loss of approximately 5 kg over 6 months. He had no hemoptysis, night sweats or fevers.

His past medical history was significant for ischemic heart disease and a coronary artery bypass graft 12 years ago. He also had a history of chronic obstructive airway disease, hypertension and hypercholesterolaemia.

Family history was significant for his mother dying from tuberculosis when the patient was two years of age. He was a smoker with a 54-pack-year history. He was a retired office worker.

His medications included an inhaled corticosteroid, a long-acting inhaled anti-cholinergic, low-dose aspirin, an ACE inhibitor and a statin.

Physical Exam

On examination, his pulse was 70 bpm and regular. He was apyrexial and had an oxygen saturation of 97% on room air. He had early clubbing. Cardiovascular exam revealed a pansystolic murmur. Respiratory exam showed decreased air entry bilaterally but no crepitations or wheeze. Abdominal exam was unremarkable.


Full blood count was normal except for eosinophils of 0.6 x109/liter (0.0-0.4 x109/liter).

Erythrocyte sedimentation rate was 88 mm/hr (1-22mm/hr) and C-reactive protein was 60 mg/liter (0-10 mg/liter).

Urea, creatinine, electrolytes and liver function tests were normal.

Based on the chest radiograph (Figure 1) and computed tomography (CT) scans (Figures 2 and 3), further laboratory investigations were obtained and bronchoscopy was performed:

Serum IgE  2378 ng/ml

Aspergillus fumigatus (m3) Antibody 12.1 ng/ml (positive)

Anti-aspergillus IgG 149 ng/ml (positive)

Anti-nuclear antibodies  negative

Anti-neutrophil cytoplasmic antibody negative

Galactomannan 0.2 ng/ml (positive >0.5 ng/ml)

Ziel-Nielson stain for acid-fast bacilli negative x3

Bronchoscopy showed no evidence of endobronchial lesion

Bronchoalveolar lavage showed gram-positive cocci and gram-negative bacilli

Transbronchial biopsy: cytology no malignant cells; histology nonspecific inflammatory changes


Figure 1. PA chest radiograph showing a left-apical cavity.

Figure 2. CT scan in the supine position.

Figure 3. CT scan in the prone position.

Question 1

What is the most likely diagnosis?


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